The past was prologue

OK, back to the nostalgia. Morning Retort has as nice an introductory post as you're likely to see. She (he?) puts blogging in context, going back to the early days of the web.

Do you remember the first time you used a browser? It would have been about 10 years ago this spring, for me. My friend Matt, the CS major from down the hall, was urging me to quit relying on gopher and FTP. He said to try this WWW thing, because the interface was cooler and you could see text and pictures at the same time. He demonstrated it for me by downloading Mosaic onto my spiffy 486-33.

And then we typed in a web address... and waited.

"It takes a while to load pages, though."

But that page did eventually load. And then another, and another. And then, I think, a popup ad for those video cameras.

Even on that spring day ten years ago, I imagined I'd have a web presence. I imagined people from around the world -- several dozen, even -- would be curious to read my words. And I thought that maybe if it didn't include pictures, it would load faster.

Years later, this would come to pass. But blogborygmi was not the beginning! The Bacon Page, with its running diary of my encounters with the greasy meat, would have to qualify as my first blog. The site also featured reader mail, including testimonials and bacon haiku. It was well-liked, and even garnered some dubious awards. Alas, I took it down when I started med school, and felt I should be promoting public health.

I didn't know about Atkins back in 1998. But bacon's emergence as a mainstream, health-conscious food seems to have taken that "forbidden meat" luster from it. Otherwise, other bacon sites may not be defunct, either.

If you've got the hankering to visit the early web of yore, check out the Wayback Machine. Early web sites are profiled, such as Amazon's first page and other relics, rescued from the dustbin of history.

Earn your doctorate online

The New York Times Science Tuesday is always enjoyable. Today, Anahad O'Connor reports on doctor / patient emails:

Dr. David Ives, a general internist at Beth Israel Deaconess who receives about 30 e-mail messages a day from his patients, said, 'Most physicians are afraid they'll be overwhelmed, but it actually replaces telephone calls for me.'

About a quarter of practicing doctors, surveys show, have communicated with patients through e-mail. But many doctors feel that it means working for free, and some have begun charging for e-mail consultations. In some cases, patients pay a flat rate from $100 to several hundred dollars a year for such services, said Dr. Daniel Z. Sands, an assistant professor of medicine at the Harvard Medical School who also practices at Beth Israel Deaconess.

'I think it's reasonable to assume that if lawyers and accountants charge for time, then physicians should, too,' said Dr. Sands, a co-author of the new journal article.

Someday, when I write about the reimbursement schemes of law vs. medicine, and the pros and cons of concierge ("boutique") medicine, Dr. Sands' quote will be the centerpiece.

Until then, I'll just say that charging for email is probably more of a concern at Boston's Beth Israel than where I did my family medicine rotation (only about 50 miles away). At my site, doctors would give email addresses to the patients who were computer literate, on the web at home, and trustworthy enough not to abuse the arrangement -- a small, small subset of patients. A payment plan was not in the works, as far as I knew.

Furthermore, answering emails seems like an attractive job to delegate to med students (after the content is reviewed by the doctor, naturally). Students would have the opportunity to take their time with the diagnosis, consider the triage, look up potential treatments, check against the hospital formulary, etc. These are skills we have to learn anyway -- and it's a lot more stressful to do when the patient is in front of you, with a full waiting room to boot. Finally, if attending chart notes are any indication, the students would be more likely to write a longer, more thorough workup -- and one the patient could understand.

Do something

It's an abrupt buzz-kill from this site's recent levity and nostalgia, but I just saw my name on Me and Ophelia's list of bloggers passionate about international justice. I'm surprised by the inclusion, and can't help but think she's politely, implicitly, challenging me to put my money where my mouth is.

Unlike the Amazon hoax I railed against last weekend, this crisis is real, and it's not getting the attention it deserves. James Moore has got the latest on the genocide in Sudan. Passion of the Present lists the ways readers can get involved.

For all our opinions and perceived influence, bloggers haven't done a whole lot to change the world. Now seems like a hell of a time to try and start. Pass it on.

Who says medicine isn't satisfying?

Overheard on rounds last week:

    Medical intern: "Any pain this morning, Mr. Jones?"
    Mr. Jones: "Yeah, actually, I was getting this sharp pain in my back overnight."
    Intern: "Can you sit up?"
    Mr. Jones rises.
    Intern: "Sir, you slept on your fork."

A chance to round is a chance to cure.

veni, vidi, venti

I went back to Providence this weekend. It's comforting to know some important places haven't changed. Others places, of course, have been adorned with a giant donkey painting. Time marches on.

Glorfindel's grateful for the nostalgic goodness of site (it's where I got the link to the Thayer Street Starbucks, above). It reminds me of the Degree Confluence Project, the goal of which is to collect photos of every land-based round-number intersection of latitude and longitude. Desert, jungle, mountain, suburb -- they're making undeniable progress.

Virtual tours of popular locations have been around for a while. On the other extreme, the TerraServer's been around for years, as well, giving a satellite's eye view of every place in the world.

But the warm fuzzies of a special memory don't come from a bird's eye view or a virtual college tour. Through the concerted action of smart mobs, we're getting closer to the day when we'll have an indexed, street-level view of every block, every store, every dorm. Even later, perhaps, a chronological view -- so we can fondly remember Thayer Street before the donkey.

Internalized Medicine

It seems my last two clerkships, Psychiatry and Family Medicine, were readily blogworthy. In addition to the medical aspects of care, our curriculum included plenty of interesting material on provocative aspects of health care, conflicts of interest, evidence-based medicine, rights of the mentally ill, personality disorders, and many more. The lighter schedule didn't hurt the postings, either.

The Internal Medicine clerkship has less room for anything other than Internal Medicine. I find it just as intriguing, actually. The problem is, it's harder to make pleural effusion palatable to a lay audience (my stats indicate a fair number of you are here to read about Quiznos subs). Doc Shazam and Hermes both do a good job of weaving patient's stories with medical information and decisions, and that's something I plan to work on... when I have a little more perspective on what's going on.

Most notably, the continuity-of-care means I'm connecting more with patients. As days go by, their ups and downs have come to affect me more than I expected, based on earlier clerkships. The other day I cheered and high-fived my resident when a patient's potassium labs came back. I can't recall being that excited about lab results during any other clerkship (if it helps to convey the drama, I'll add that she had RTA and had just started a course of Amphotericin B).

The downs are real downers, though. Our team had a storm cloud over us today, following some surprisingly bad news relayed by the night float. A small consolation: it might make a good teaching case... with some more perspective.

The Good Fight

Everyone at my school got a mass-mail this weekend, from a fellow med student. The subject was "Environmental Crisis at Hand," and it was addressed to "those with an environmental conscience."

The urgent message went on to describe an upcoming vote in the Brazilian congress -- a vote to chop down the Amazon rainforest to 50% of its current size, so as to make way for grazing. But if the recipients each add their names to the petition right now, and forward it to some Brazilian representatives, they might listen. Because (and here I paraphrase SNL) -- "we have to stop this tree thing!"

I had been in a foul mood to begin with -- the Sox were losing, I was behind on my weekend workload, and my car lost a hubcap. Certainly, this preposterous spam didn't help. I know not everyone is as plugged-in to current events as the blogging community, but I'd like to think my classmates can spot a ridiculous story when they see it. Honestly, I don't know what's harder to believe -- the plan to cut down the forest, or the idea that emails could stop it.

I found a description of this 4-year old hoax at Snopes, and I forwarded it to my classmate, the spammer. She's one of those hardcore activists I've written about previously. She organizes meetings about social justice, brings in speakers, holds bake sales. She spent a summer giving vaccinations in Tanzania, and I think she did a rotation in Viet Nam. She'll have her MD soon, and will continue to work hard for these causes she believes in. But here I was, irritated that she wasn't more jaded, less naive.

I tried to gently communicate this to her. I remarked that she'd spammed the school for nothing, but at least she was being environmentally conscientious. I was insinuating that her sense of righteousness had crowded out some of her finer critical faculties.

Today she replied to my message. She didn't catch my jibe at her. In fact, she thanked me for the explaining the hoax. She added, "It's beyond me why people would start this sort of thing."

And she's right: It is beyond her. She works hard to promote what she thinks is right. She thinks she can make a difference. She trusts others to do the same, and is surprised and disappointed when they don't.

I hope she never changes.

These are days

Spring in New England this year seems to have lasted about 36 hours -- we went right from rainy cold dreariness to sunny with mid-eighties temps in a matter of days. Throw in the Red Sox / Yankees matchup, and it sure feels like summer.

There's a bunch of albums that usually find their way into my stereo during the first warm days of spring: Big, bright, loud music from the Dandy Warhols, Throwing Muses, They Might Be Giants, David Bowie, and others. There hasn't been enough time for that, this year -- there's a traffic jam outside my disc-changer.

In terms of songs commemorating the joy and sadness of passing seasons, I used to think nothing could top the epic "Rain Song" by Led Zeppelin. But I finally paid attention to the lyrics of Nick Drake's "River Man", and realized it was about the journey into and out of winter. It's not bright and loud, but nevertheless it's spring music to me. Play it in the wee hours of a crisp spring night, in your car, while going to pick up some donuts and coffee to fuel another few hours of study. See if you don't pull over, stare at the traffic, and think wistfully of that vast field near where you grew up.

Dammit, Jim

This BBC story gives Trekkies everywhere another reason to go into medicine:
US firm Vocera has created a wireless voice communicator just like they use in Star Trek: The Next Generation. Similar to the TV series, all you do to contact someone is press the talk button on the lapel badge, say their name, and you will be put through.

The gadget is proving popular in hospitals to make it easier for nurses to find and get advice from doctors.

The BBC article doesn't say whether this Wifi gizmo makes a chirping sound when pressed -- or whether its users tend to look up or away when speaking through the device. The next version will apparently let users beam directly into patient rooms, substantially improving the efficiency of morning rounds.

On a slightly more serious note, it seems a lot of thinking about future health technology is already hopelessly intertwined with Star Trek. The invention of real hyposprays, like the kind Dr. McCoy uses, was just the beginning.

Finally, I never get the chance to bring this up, but the term "hypospray" actually predates the original Star Trek, going back to WWII mass-inoculation efforts. Sadly, the term hasn't appear on medline in 30 years. Also, the term "biobed" has similarly fallen on hard times.

Student talk

The blogging's been lighter, and may continue to be lighter for a little while longer. I've been working on a couple of articles for another publication, and keeping up with my medicine rotation.

Other medical students have plenty to say, however. I used to think there were only a handful of med-student bloggers. It turns out there may be as many as several handfuls.

In addition to the fine bloggers showcased on the right, some new med student writers have come to my attention recently:

  • Anjali Taneja and friends run to the teeth, a blog about social and health care justice. Anjali's been working as a fellow at AMSA this past year. She made some good points on my earlier post about tactics for raising awareness of medical issues, because, well, she does more than just write about justice.

  • A student blog at Case Western, Medipol's Down on the Farm is another site that mixes medicine and politics.

  • Across the pond, This Won't Hurt a Bit is being set up by an introspective student. His latest post indicates he might soon be moving to France. Fortunately, his "comments" feature is enabled.

  • Two med student blogs that are new to me, but have apparently been around for a while, are Intueri and Future Evil Resident. They're both based in California, and they're both 4th years, so get 'em while they're students.

Carrageenan is forever

I had a vegan roommate a few years back; our kitchen was fascinating. Among other culinary innovations, he got me hooked on Cuties -- little ice-cream sandwiches, without ice cream. Instead, they've filled it with some kind of vanilla-flavored soy paste. It sounds like an abomination, but then again, that's what he'd say about my Chicken Voila.

The proof is in the pudding, and the truth is Cuties are actually quite good. Now you can try them free, with a coupon from the Tofutti company.

Hospital Hijinx

The Onion provides some helpful hints for those going to a hospital, such as:

  • Pack several extra pairs of slippers. Slippers in the hospital are like cigarettes in prison.

  • Bring $500 in fives to "grease the wheels," if you get my meaning. The good mashed potatoes.

  • If bruised, find a hospital known to have a good bruise ward.

It's a good bet this will appear in a chart room or two, by the end of the week.

Arndt Revisited

After the Boston Globe Magazine ran a piece on a self-destructive surgeon from Harvard, I corresponded with the author, Neil Swidey. The Globe ended up running a condensed version of my earlier post in the Letters section of the Magazine this past Sunday.

But buried in the "Online Exclusive" bonus letters-to-the-editor is this:

Just finished reading your article on David Arndt "What went wrong?" As a practicing psychiatrist with long time experience with treatment of addictions, I could not stop asking myself why nobody involved in his case apparently considered whether David has bipolar disorder. His life pattern so well described by you is very typical. His escalating drug abuse along with deteriorating professional functional are indicative as well. It seems to me that drug dependence as well as all other doings came secondary to underlying mental illness.

Narcissistic PD patients never get so self-destructive. At no point of their life they are liked by anybody.

Bela Bochkarev, MD, Uxbridge

Oh, well. OK. Good to know. But I'm not done with the amateur tele-psychiatry yet. Not to put too fine a point on it, I never meant to say Dr. Arndt met DSM criteria for a personality disorder; he just has narcissistic traits. He found a place where his personality didn't get in the way, and he prospered -- like an obsessive who gets to organize closets for a living. It's only when he started his own practice, had less oversight and more responsibility, that things started to unravel for him. Is this worsening bipolar disease, or just exposing fixed, maladaptive personality traits? As good as Swidey's article was, it's no basis for making a diagnosis.

Into the foxhole

Nasogastric tube insertion is one of the first procedures I learned as a third-year. It's no wonder my residents were eager to delegate this to the med student -- it's one of the most unpleasant procedures I've learned, as well.

Even the most out-of-it patients raise a mighty ruckus when you try quickly jam two feet of plastic down through their nose, down their esophagus, and into their stomach. In the handful of NG tubes I've inserted, I've seen patients gag, spit, grasp, cry, and moan -- and that's before I even unwrap the kit.

The other day I was charged with this task. The patient was a frail, elderly immigrant who needed small bowel decompression. She'd been given an NG tube on admission, but GI took it out for her ERCP. I had to put a new one in, so that, you know, her vomit and gastric secretions could be efficiently extracted and measured.

The patient and I got along well enough; I think I'd made her smile once or twice, despite her pain. She had a large family who was often around to help with translation, and today her nephew was in the room with us. The patient remained silent but eyed me suspiciously as I informed her of the need to reinsert an NG tube.

I set up my supplies, got the patient into position, lubed the tube, and began. Initially, things went well. There's always a little resistance as you round the bend past the nasal vault, but I passed it with relative ease. My patient was gagging and drooling everywhere, and I think at one point, she actually hissed. But I was quickly making progress when the tube just stopped. It was a good 6 inches from my selected marker. I pushed a little more but got nowhere.

My patient was not pleased. Her eyes were bulging, she coughed repeatedly, and tried to swallow. Her wrinkled face was disturbingly animated.

Maybe I marked the tube's endpoint too liberally. I chalked it up to a rookie mistake. My intern agreed and pushed some air through the tube, while listening for stomach inflation. Satisfied, we taped the tube to the patient's nose, and made the standard call for an x-ray to verify placement. With some apologies for the discomfort, we headed out.

I was paged twenty minutes later. The x-ray team was ready, but the tube had come out. What's more, the patient was vomitting. Could someone try this again?

This time, the third-year resident took over. He wordlessly moved into the room and quickly began to set up. When my patient saw we'd try again, she started to shake her head and gesture to her nephew. She spoke to him in a resigned tone with her raspy voice.

"No more!" he interpreted. "It hurts, it gets stuck."

My resident, himself a non-native speaker of English, looked up and said, "No more pain. Won't get stuck. Ready?"

The tube went in quickly and effortlessly. I still don't know what he did differently. My patient's eyes were closed, and she opened them when she realized it was over so soon. Her expression was one of surprise and relief.

I shook my head and remarked, "He's really good."

With her pan of vomit still in her lap, she turned to me and her expression changed. In her crackly voice and broken English, she nodded and said, "Better... than you."

As the world turns

Today Christians celebrate Good Friday -- all of them. This actually stands in contrast to most years. Usually the Orthodox (Greeks, Russians, and others), observing the Julian system, celebrate Easter week later than the Catholics, Protestants, Lutherans, Anglicans and others on the Gregorian calendar.

As it's explained by Dr. Lewis Patsavos of the Holy Cross School of Theology:
The determination of the date of Easter is governed by a computation based
on the vernal equinox and the phase of the moon. According to the ruling of
the First Ecumenical Synod in 325, Easter Sunday should fall on the Sunday
which follows the first full moon after the vernal equinox. If the full moon
happens to fall on a Sunday, Easter is observed the following Sunday. The
day taken to be the invariable date of the vernal equinox is March 21.

Herein lies the first difference in the determination of Easter between the
Orthodox Church and the other Christian Churches. The Orthodox Church
continues to base its calculations for the date of Easter on the Julian
Calendar, which was in use at the time of the First Ecumenical Synod. As
such, it does not take into consideration the number of days which have
since then accrued due to the progressive inaccuracy of the Julian Calendar...

Peter Meyer at Hermetic Systems explains the dilemma in these stark terms:
The average length of a year in the Julian Calendar is 365.25 days (one additional day being added every four years). This is significantly different from the "real" length of the solar year... this error accumulates so that after about 131 years the calendar is out of sync with the equinoxes and solstices by one day. Thus as the centuries passed the Julian Calendar became increasingly inaccurate with respect to the seasons. This was especially troubling to the Roman Catholic Church because it affected the determination of the date of Easter, which, by the 16th Century, was well on the way to slipping into Summer...

Something had to be done to bring Easter back to Spring, yet try to keep it after Passover. Compromises and upheavals followed. What I find particularly fascinating are the significant calendrical consequences of this split, and how they continued well into the last century:
When Pope Gregory XIII was elected he found various proposals for calendar reform before him, and decided in favor of that of Clavius. On 1582-02-24 he issued a papal bull, Inter Gravissimas, establishing what is now called the Gregorian Calendar reform...

  • Ten days were omitted from the calendar, and it was decreed that the day following (Thursday) October 4, 1582 (which is October 5, 1582, in the old calendar) would thenceforth be known as (Friday) October 15, 1582.

  • The rule for leap years was changed. In the Julian Calendar a year is a leap year if it is divisible by 4. In the Gregorian Calendar a year is a leap year if either (i) it is divisible by 4 but not by 100 or (ii) it is divisible by 400. In other words, a year which is divisible by 4 is a leap year unless it is divisible by 100 but not by 400 (in which case it is not a leap year). Thus the years 1600 and 2000 are leap years, but 1700, 1800, 1900 and 2100 are not.

  • New rules for the determination of the date of Easter were adopted.

  • The position of the extra day in a leap year was moved from the day before February 25th to the day following February 28th.

The Gregorian Calendar was adopted in Britain (and in the British colonies) in 1752, with (Wednesday) September 2, 1752, being followed immediately by (Thursday) September 14, 1752...

In many countries the Julian Calendar was used by the general population long after the official introduction of the Gregorian Calendar. Thus events were recorded in the 16th to 18th Centuries with various dates, depending on which calendar was used. Dates recorded in the Julian Calendar were marked "O.S." for "Old Style", and those in the Gregorian Calendar were marked "N.S." for "New Style"... Sweden adopted the Gregorian Calendar in 1753, Japan in 1873, Egypt in 1875, Eastern Europe during 1912 to 1919 and Turkey in 1927. Following the Bolshevik Revolution in Russia it was decreed that thirteen days would be omitted from the calendar, the day following January 31, 1918, O.S. becoming February 14, 1918, N.S.

It's neat to think a decree can erase whole weeks from history -- it makes the Orwellian Daylight Saving system seem, well, benign. But why didn't everyone sign onto the Gregorian system?

As Dr. Patsavos further explains,
The need for correction of
the Julian Calendar was well understood in the East and had even led some to
devise a new calendar themselves. Nevertheless, the Julian Calendar remained
in use throughout the Byzantine period and beyond. Despite the efforts of
the emissaries of Pope Gregory to convince the Orthodox to accept the New
(Gregorian) Calendar, the Orthodox Church rejected it. The main reason for
its rejection was that the celebration of Easter would be altered: contrary
to the injunctions of canon 7 of the Holy Apostles, the decree of the First
Ecumenical Synod, and canon 1 of Ancyra, Easter would sometimes coincide
with the Jewish Passover in the Gregorian calendar.

So each side had their priorities, and the differences persisted. Eventually the Orthodox and Western churches developed different "Paschal cycles" of varying years, so that Easter could be calculated with some consistency in perpetuity. Things will line nice up nicely for all Christians again in 2007 and 2010. Next year, however, Orthodox Easter will fall over a month after Gregorian Easter (May 1 vs. March 27).

Most years, we all make do with some confusion, some lengthy explanations, and some groups taking advantage of heavily discounted Easter bunnies. Is it worth it? Unquestionably. Preserving these differences gives us insight into humanity's ancient perceptions of time, space, the seasons, and God. We're far richer for it.

Flip of a coin

Yahoo! / AFP reports that, when the earth's magnetic field flips, it takes about 7000 years to do so. The frequency of inversion is still considered to be about once every half-million years or so -- meaning we're overdue.

I had mused in an earlier post that we, as a society, were lucky that the magnetic field was around when navigators really needed it (the past several hundred years) and that without it, a global civilization might never have developed. Turns out I understated the other benefits of the magnetic field:

Many aspects of life today would be literally turned upside down, both for humans, given our dependence on magnets for navigation, and for migrating animals which use an inner compass.

We would also be more exposed to deadly busts of solar radiation, from which we are normally protected by Earth's magnetic field. And the loss of that shield would cause solar particles to smash into the upper atmosphere, warming it and potentially causing wrenching climate change.

I'd chance the loss of the magnetic field now in terms of navigation -- global commerce can safely make the transition to GPS with only minor disruption if the magnetic field slowly vanished. Also, the migratory animals might get confused but would probably bounce back in some form. But the wrenching climate change could ruin your whole day.

Practice for a Practice

I figured this article would get some play over at Cut to Cure:

Surgeons Who Play Video Games Err Less

All those years on the couch playing Nintendo and PlayStation appear to be paying off for surgeons. Researchers found that doctors who spent at least three hours a week playing video games made about 37 percent fewer mistakes in laparoscopic surgery and performed the task 27 percent faster than their counterparts who did not play video games.

(I'll bet video-game players are better drivers, too.)

I assuming the study picked adequate controls, though it's possible that non-video-game playing surgeons operate on harder cases, or work longer hours. What really encourages me is the following:
Beth Israel is now experimenting with applying the findings. Rosser has developed a course called Top Gun, in which surgical trainees warm up their coordination, agility and accuracy with a video game before entering the operating room.

"It's like a good football player," Rosser said, "you have to warm up first."

Exactly! Surgeons should play video games before laparoscopy. Pediatricians should warm up with a game of tag every morning before seeing kids. Psychiatrists should simply ride the subway. And Internal Medicine? They should walk back and forth around their house, asking the furniture and house plants to hurry up with those results.

UPDATE: I'd rather comment on the video game study than today's other popular new study. The comments at this site are really... on the ball... suggesting that it's not the deed but the impulse that's protective.

Running scared

My Internal Medicine clerkship began today, and I was on long call. When my resident said we'd cap at ten admissions, I felt real fear for the first time since Surgery. At some point today the fear gave way to hunger, and now sleepiness.

Speaking of fear, check out this New York Times magazine piece on desensitizing the formation of traumatic memories. There's a human trial underway of a CNS-acting beta-blocker (propanalol) that, in rats at least, seems to dull the feelings that get encoded along with painful memories. The facts of a trauma are retained without the terrible emotions that can accompany them.

There's potential for preventing flashbacks, dissociative states, avoidance, and all the terrible things that go with PTSD (post-traumatic stress disorder). But the author of the piece, Robin Marantz Henig, asks if our society will be better off this way:

''Would dulling our memory of terrible things make us too comfortable with the world, unmoved by suffering, wrongdoing or cruelty?'' asks the bioethics council in its report. ''Does not the experience of hard truths -- of the unchosen, the inexplicable, the tragic -- remind us that we can never be fully at home in the world, especially if we are to take seriously the reality of human evil?'' The council also asked whether the blunting of our recollections of ''shameful, fearful and hateful things'' might also blunt our memories of the most wondrous parts of our lives. ''Can we become numb to life's sharpest arrows without becoming numb to its greatest joys?''

Still, to scientists who study memory, there is nothing beneficial, for either individuals or for society, about debilitating, unbidden memories of combat, rape or acts of terrorism. ''Going through difficult experiences is what life is all about; it's not all honey and roses,'' said Eric Kandel, a professor of psychiatry and physiology at Columbia University. ''But some experiences are different. When society asks a soldier to go through battle to protect our country, for instance, then society has a responsibility to help that soldier get through the aftermath of having seen the horrors of war.''

Of course, post-battlefield remorse serves as a check on our militaristic tendencies. Vietnam veterans haunted by memories of combat were among the most forceful opponents of the war after their return home. But have we the right to buy a surrogate conscience at the cost of thousands of ruined lives? If we have the responsibility to treat veterans' physical wounds, don't we also have a responsibility to ease their psychic suffering?

...Without witnessing the torment of unremitting post-traumatic stress disorder, it is easy to exaggerate the benefits of holding on to bitter memories. But a person crippled by memories is a diminished person; there is nothing ennobling about it. If we as a society decide it's better to keep people locked in their anguish because of some idealized view of what it means to be human, we might be revealing ourselves to be a society with a twisted notion of what being human really means.

Was Charlie Kaufman thinking about this when he wrote "Eternal Sunshine for the Spotless Mind" ? I really should see that, if I get the chance.

As a service to our readers

The blogborygmi online store is now open! Following the fine example of other medical bloggers, now you can purchase items for your kitchen and torso. Each item proudly displays the spiffy new blogborygmi logo, developed by graphic designer Gene Yoon.

With every item you purchase, one penny will go toward upkeep of the this site. Isn't it blogger free, you ask? Well, yes, but I went ahead and purchased some domain names for your convenience. Looking over some of the bizarre and specific google searches that led to this site, I could only conclude that people are having a hard time remembering the address.

So, to simplify things, and now point to this blog. If the readership heads over to the store and buys 2940 mugs or T-shirts, this extravagance will pay for itself!

Ticketless travel

Instapundit and Rand Simberg ( are discussing a Long Island police union's request that officers and their families be immune from speeding tickets. Simberg writes:

While this is outrageous in itself, it would seemingly put the lie to the notion that the purpose of such laws is for public safety, since it's no "safer" for a police officer's wife to speed than it is for anyone else. It's a tacit admission that it's all about revenue generation, and just as government workers shouldn't necessarily have to pay taxes (since they're paid from taxes), they shouldn't be subject to this revenue device either. Remember this the next time you hear a lecture from a cop about how dangerous it is to exceed the speed limit.

I disagree that speeding tickets are "all" about revenue generation, though it's probably a component (this contention is hotly debated.)

The police union's request might be an awkward, stumbling step in the right direction: acknowledging that some speeders are safer, and therefore less punishable. While Simberg's point about the police officer's wife is well taken, I would maintain the officer, with his cruiser training, is probably not a risk to himself or the public if he's a few miles over the limit. This is probably also true of ambulance operators and other professional drivers. Right now we're all at the mercy of the police officer's discretion. Why not adjust the law (or the contesting process) to accommodate the reality: some people's speed limits should be higher.

Already many roads feature adjustable speed limits, which depend on weather conditions or construction. Ultimately, all speed limits could be personalized, depending on one's accident record, age, and other variables. The issue could come to a head if GPS trackers become mandatory in cars (some rental car companies have already put this in place). With constant speed monitoring in place, two possibilities present themselves: Either everyone will get ticketed the moment their car passes the speed limit, or we'll have constructively correlated speeding data with driving records, to see who can safely manage higher speeds.

Though on the surface the police cronyism cited above may seem repulsive, it might lead to something positive. At any rate, it's the first honest acknowledgment I've seen that speed limits are unnecessarily restrictive for proven, skilled drivers.

UPDATE: More great stuff over at in the comments section. Here's one from a guy named Hefty:
Yes police officers go through special training for driving: vehicle dynamics, skid control, braking control, accident avoidance. Basically what is talked about in most drivers educations courses but they actually get to do some of it. Anybody can sign up with a specialized driving school or race car school to practice the same things, Skip Barber Dodge driving school is a good example. Some detectives will get sent off to other specialized training workshops where they learn how to set spike strips, how to ram cars off the road, and best ways to coodinate road blocks, shoot tires out, etc. Thats why you will see a car chase on the news and several cop cars will be following behind the getaway car for a while, just hanging back. Then, the detective will appear and you will see them zoom out ahead of everything and actually do something to try and stop the getaway car. Alas, I'm quite certain they feel entitled and above everyone else cause of all this 'top notch' training they've received. It sounds like a lot of training but most of it only takes a day or two to go over.

And Bob writes:

The injury/death rate is higher at slower speeds (less than 60) than at higher speeds (greater than 80.) Anybody can make an unchallenged statement like you did because we have been indoctrinated with "speed kills." It ain't so! Speed limits, for the most part are revenue sources and have nothing to do with public safety.

Let's do the time warp again

I'm half-expecting the Proximal Tubule to weigh in against this weekend's government-imposed intrusions into our homes, our heads, and our clocks and watches. Sure, people enjoy more sunlight, and DST serves a useful role for industry, and it actually seems to save lives (see below). You've got to admit, however, there's also something Orwellian about Daylight Saving Time.

A wonderfully comprehensive history of DST is available. It goes back to Ben Franklin's original proposition, through the widespread but inconsistent adoption in the first and second World Wars (including "Double Summer Time" -- two hours ahead in Britain), to today's whacky implementation. They list all the world's idiosyncrasies in adopting this "standard" -- from the 30 minute increments in India, to China's "one-time" policy, to the mess that is Indiana. Here's more:

Part of the confusion is because the phrase Daylight Saving Time is inaccurate, since no daylight is actually saved. Daylight Shifting Time would be better, but it is not as politically desirable. In fact, scientifically misguided politicians sometimes misunderstand. In 1995, the British Time (Extra Daylight) Bill was introduced by John Butterfill, attempting the impossible -- to legislate extra daylight. The bill did not pass...

Daylight Saving Time "makes" the sun "set" one hour later and therefore reduces the period between sunset and bedtime by one hour. This means that less electricity would be used for lighting and appliances late in the day.

...Following the 1973 Arab Oil Embargo, Congress put most of the nation on extended Daylight Saving Time for two years in hopes of saving additional energy. This experiment worked, but Congress did not continue the experiment in 1975 because of opposition -- mostly from the farming states.

In 1974, Daylight Saving Time lasted ten months and lasted for eight months in 1975, rather than the normal six months (then, May to October). The U.S. Department of Transportation -- which has jurisdiction over Daylight Saving Time in the U.S. -- studied the results of the experiment. It concluded:

Daylight Saving Time saves energy. Based on consumption figures for 1974 and 1975, The Department of Transportation says observing Daylight Saving Time in March and April saved the equivalent in energy of 10,000 barrels of oil each day -- a total of 600,000 barrels in each of those two years.

Daylight Saving Time saves lives and prevents traffic injuries. The earlier Daylight Saving Time allowed more people to travel home from work and school in daylight, which is much safer than darkness. And except for the months of November through February, Daylight Saving Time does not increase the morning hazard for those going to school and work.

Daylight Saving Time prevents crime. Because people get home from work and school and complete more errands and chores in daylight, Daylight Saving Time also seems to reduce people's exposure to various crimes, which are more common in darkness than in light.

The Department of Transportation estimated that 50 lives were saved and about 2,000 injuries were prevented in March and April of the study years. The department also estimated that $28 million was saved in traffic accident costs.

Well, that's all well and good, but who's going to adjust my VCR? What's worse, now that we've let the governments of the world dictate what time it is, we're headed down the slippery slope. Future possibilities:

  • Changing the temperature in the winter, so it seems warmer (encouraging more outdoor commerce)

  • Adjusting spedometers in sports cars, so drivers think they're going faster (reducing traffic accidents)

  • Change the definition of "causes of death" so to fuel the obesity crisis (wait -- they already did that)

You know those people who set their watches ahead by a few minutes, so they're never late? Why can't they just adjust their conception of time, instead? Daylight Savings seems to validate this laziness on a grand, state-enforced scale. I'm going to organize a protest march against DST. We'll meet at high noon, Sunday... whenever that is.

No-win scenario

Conservatives claim that allowing gays to marry will ruin marriage for all people. And now, according to the Boston Globe, they're working hard to fulfill their prophecy::

Lawmakers and activists on both sides of the issue suggest that Romney may be weighing several options, including an executive order to block the issuance of licenses to gay couples; proposing a law to prevent issuance of those licenses; or backing another bill, being pushed this week, that would abolish marriage entirely and create civil unions for heterosexual couples, as well as gay couples.
..."It's absolutely radical, but it's consistent," Loscocco said. "In my view, this is something the Legislature has to weigh..."

Another Massachusetts man once said, "A foolish consistency is the hobgoblin of little minds." One wonders if Republicans have really weighed another consistent option: let couples get married. It seems less radical all the time. We're talking about an institution that has survived things like Elizabeth Taylor's eight nuptials, or Britney's 55-hour marriage. But when pitted against the obstinate, unthinking right, marriage may have met its match.

Doctor without borders

When I was in New York this week, I had the chance to meet up with Dr. Sheri Fink. She's the author of War Hospital, the story of a group of young doctors in Srebrenika during the Bosnian war.

She has a fascinating career path: an MD and a PhD (which she doesn't always mention), a postdoc grant to study in Bosnia for a year (which turned into the foundation for the book) and now, freelance journalism and opinions.

Next week she's off to Iraq on an assignment for Discover. She has spoken about her last trip to Iraq, at the height of the war last year. Join me in wishing her another safe return.

UPDATE: Me and Ophelia's got a transcript of Dr. Fink's chat session on wapo last November, and more links and commentary about medical issues in the Balkans.

Soft sell, part II

Regarding the new, gentler approach to persuasion that I remarked upon in my last post: It's too late to educate the students in my med school lobby. Right now they're sitting by their posters proclaiming "if you're not outraged, you're not paying attention" and "if fifty planes crashed every day, would you find that acceptable?" Earlier today, they were apparently accosting people and waving around airport landing beacons.

The students are raising awareness for AIDS week, but it might as well be tobacco or cholesterol or speeding on the highway. "Raising awareness" is a laudable goal, but I suspect the people walking through our lobby already know a fair amount about health issues. What's more, I doubt these poor employees appreciate being told they're ignorant if they're not perpetually outraged. As Meyers asks in the Atlantic , is this about persuasion... or punishment?

These organizers have plenty the facts about AIDS in Africa, but a dim understanding of human nature. They are no doubt gathering some signatures for future mailings and meetings, and maybe even raising a little money along with awareness. But I'd wager they'd be more successful if they adopted a less confrontational, jarring approach. Unfortunately, though a soft sell approach might be more successful, I think the organizers would find it less satisfying. I don't expect things to change at next year's AIDS week.

UPDATE: blogborygmi has learned that Al Roker's colon was on national television this morning, as part of the colon cancer awareness campaign. I haven't decided if this approach fits with "gentle persuasion", "shock and rattle", or if it needs a new category altogether.

Soft sell

Psychoanalyst-turned-animal rights activist Jeffrey Moussaieff Masson has written a book with a subtler, more persuasive style than his PETA counterparts. The Atlantic book review gives it a compelling context:

This is a free country (for human beings), and the American meat eater doesn't need to consider anything he doesn't want to. Try forcing him, and he will only conclude ... that the whole exercise has more to do with punishment than persuasion.

That Masson has grasped this is evident right from the start of his book, in an anecdotal preface devoted to the singing pig of the title. It's not much of a story, at least not as it's told, but it's a happy one, and its context establishes the sixty-two-year-old author as a relaxed and amiable family man. "A nice person like you can't possibly know what wonderful, sensitive creatures farm animals are," Masson seems to be saying to us throughout, "or you wouldn't be paying people to brutalize them, would you?" This approach keeps things positive despite the sad notes struck on every page. It's possible that Masson is consciously using an old child-rearing ploy to appeal to our better natures ("What you don't realize when you pull your sister's hair is that it hurts her"), but I doubt it. He seems genuinely excited about being able to tell us that pigs prefer to be clean, and that a mother hen is as protective of her young as, well, a mother hen. The familiarity of these revelations is both touching and humbling, as is Masson's belief that "in general, the more we know about something, the more we care." Who's to say that this simple faith in human understanding and compassion won't induce some readers to justify it?

The review, by B.R. Meyers, goes on to distinguish Masson's style from the thorough, philosophical arguments of Peter Singer's Animal Liberation, or the exhaustive research of Scully's Dominion. He goes on to say:

The ethological thrust of Masson's book is therefore no more likely to change our behavior than the other arguments he tosses in for good measure—philosophical and moral arguments that the animal-rights movement has spent decades preaching to a world that can barely be bothered to look up from its plate. As the heroine of J. M. Coetzee's Elizabeth Costello (2003) concludes in one of her lectures, our hearts are closed to animals; we have the capacity to imagine their suffering, "but choose not to exercise it."

It's not just PETA and the animal rights movement that's shifting tactics. I recently encountered a worker for Children's International in Washington Square. She and a half-dozen others were out there with a clipboard and pamphlets, cheerfully asking passersby to sponsor disadvantaged kids in poor countries. In speaking with her, she revealed that one week of canvassing the streets of Manhattan yields as many child sponsors as a year of advertising on TV, radio, and internet.

It would seem that, when it comes to confronting people with unpleasant realities, it doesn't pay to persuade, to educate, or to "prove" how bad things are. It's best to gently, repeatedly nudge some notions into people's minds, while taking care not to overwhelm or accuse. I suspect many funding and advertising organizations have known this for a long time; certainly many successful charities employ the gentle nudge. In the Boston area, the Jimmy Fund campaigns for the Dana-Farber cancer institute come to mind as a positive example.

I wonder if the cause itself leads attracts a particular kind of activist, and encourages a particular style of ad campaign. Maybe because animal and child suffering is essentially preventable, whereas cancer is not, activists in the past chose to shock, rattle and educate people out of their ignorance and apathy. The zeal and righteousness of these activists may have been preventing them from grasping some fundamental aspects of advertising, and of human nature.

Collecting Duct

So, I go to New York City for a few days, and what do I miss? The biggest thing to hit mediblogs since the MMR / autism retraction. I'm referring to Trent McBride's new groundbreaking series in the Proximal Tubule on paternalism in medicine. The first section, on the history and excesses of prescription regulations, came out this week. It's provocative and well researched, and everyone's abuzz. Trent's doing a good job rounding up the commentary on his site.

Since I'm late anyway, I'm going to sit this one out and and jump in on an upcoming installment... I'm told there's lots more to come, and if it's as interesting as the "Gatekeepers" piece, we'll have plenty to think about.

The last laugh

I enjoy a good April Fool's day prank. I also enjoy spending the day second-guessing all the headlines. Is Google's new G-mail service a prank? Are the New Kids on the Block really getting back together? Where can I buy some caffeinated soap?

At least for one day a year, you can really reflect on how absurd a lot of the news really is. But if you can't stand the uncertainty, a collection of today's online pranks, including a "questionable-but-true" section, is avalaible at Snopes. And Wired has an article on what makes some web hoaxes successful.

You schmooze, you lose?

Nick Denton's Kinja debuts today. It's another blog aggregator, and lets users make editing suggestions and store their preferences. I mention it because of a quote in todays NYTimes Circuits:

Meg Hourihan, Kinja's project director and a founder of the blog publishing service Blogger, said she was ambivalent about the trend toward smaller and smaller scraps of information: "If you read 500 snippets, you can seem really up to speed at a cocktail party, but are you really prepared to make good decisions about the world?" At least with Kinja, she said, gathering those snippets is a more efficient process.

I'm not convinced any of these aggregators will ever catch on; I think people enjoy going to a few individual sites, with distinctive designs and unique voices. The whole aggregation movement reminds me of the Internet Channels concept, which was the Next Big Thing in 1997 or so -- a solution looking for a problem.

But Hourihan is right to be concerned. People only have so much free time for reading, and if we're using that time to read our favorite, narrow-scope blogs, we might miss out on the big picture (I touched upon this last year in the Boston Herald, with respect to media coverage of the Rhode Island nightclub fire. The piece is available on Lexis-Nexis).

What really strikes me about the above quote is the mention of cocktail parties. I'm consistently surprised at how cocktail parties are a major, unacknowledged force in decision-making. Right now, my classmates in medical school are trying to plan their fourth years and choose their specialties. I never suspected such significant decisions would be swayed on the basis of percieved social interactions, but it's happening. Anesthesia, for instance, has a poor cocktail party chachet, though it's rewarding in other ways. I suspect dermatology is great for get-togethers. My psychiatry rotation provided some interesting acecdotes, but I remember it also made people a little uncomfortable.

Acknowledging the cocktail party factor in decision-making is a step in the right direction. But it's still unclear what people mean by it -- Hourihan's quote suggests cocktail party stories are about impressing people without taking the time to really know a subject. Style over substance, in other words. A more benign view is that people like sharing the most stimulating information experiences possible, and they pick their news sources, and careers, accordingly.